MEDICARE: BACK TO BASICS - CHIROPRACTIC HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1598003741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO BASICS - CHIROPRACTIC HEALTH CENTER

Provider Business Mailing Address
First Line	:	112 E MCMURTRY AVE
Second Line	:	SUITE #7
City	:	HARTFORD
State	:	KY
Zip	:	42347-1634
Country	:	US
Telephone Number	:	270-298-0077
Fax Number	:	270-298-0078

Provider Business Practice Location Address
First Line	:	112 E MCMURTRY AVE
Second Line	:	SUITE #7
City	:	HARTFORD
State	:	KY
Zip	:	42347-1634
Country	:	US
Telephone Number	:	270-298-0077
Fax Number	:	270-298-0078

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. TIMOTHY SHANE VINCENT
Credential	:	D.C.
Telephone Number	:	270-256-3727

Provider Enumeration Date	:	01/23/2013
Last Update Date	:	01/23/2013

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